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TwoBriefTeachingCases
JamesMerlo,NERC&JakeMazulewicz,DominionVAPower__________________________NERCHumanPerformanceConferenceMarch2021?2021.Dominion.Allrightsreserved.2Couldthishappenatmycompany?Thesecasestudiesareintendedonlytofosterthoughtfuldiscussionandmaynotshowcorrecttechnicalprocedures.ConsultyourofficialresourcesandyourSupervisorforcorrectpoliciesandprocedures.Namesanddetailsinthiscasemayhavebeenchangedandmaynotrepresentanyoneactualevent.3TheFirstEvent
4TheCause
5TheCause
6TheCause
7TheCause
8
Turntothepersonnexttoyou.
Spendafewminutesfindingouttheiranswertothisquestion.
Ifthisincidenthappenedatyourcompany,whatCorrectiveActionwouldbetaken,andwhatwouldtheresultsbe?Question9TheCause
10The
Cause
Apparent
114-8Questions
Turntothepersonnexttoyou.
Workingtogether,writedown4-8questionsyourealisticallycouldandwouldaskinaRootCauseAnalysisofthisevent.12TheRootCause
Whatcausedhimtoremovetheshield?
13TheRootCause
Whatcausedhimtoremovetheshield?Didsomeonetellhimtoremoveitordidhedoitonhisown?
14TheRootCause
Whatcausedhimtoremovetheshield?Didsomeonetellhimtoremoveitordidhedoitonhisown?Didheremoveitjustthisonceordoesheremoveiteverytime?
15TheRootCause
Whatcausedhimtoremovetheshield?Didsomeonetellhimtoremoveitordidhedoitonhisown?Didheremoveitjustthisonceordoesheremoveiteverytime?Didhemakeanerror,ordidheplantoremoveit?
16TheRootCause
Whatcausedhimtoremovetheshield?Didsomeonetellhimtoremoveitordidhedoitonhisown?Didheremoveitjustthisonceordoesheremoveiteverytime?Didhemakeanerror,ordidheplantoremoveit?Wastheshieldlabeledasasafetydevice?
17TheRootCause
Whatcausedhimtoremovetheshield?Didsomeonetellhimtoremoveitordidhedoitonhisown?Didheremoveitjustthisonceordoesheremoveiteverytime?Didhemakeanerror,ordidheplantoremoveit?Wastheshieldlabeledasasafetydevice?Washetrainedorcertifiedtodothisprocedure?
18TheRootCause
Whatcausedhimtoremovetheshield?Didsomeonetellhimtoremoveitordidhedoitonhisown?Didheremoveitjustthisonceordoesheremoveiteverytime?Didhemakeanerror,ordidheplantoremoveit?Wastheshieldlabeledasasafetydevice?Washetrainedorcertifiedtodothisprocedure?Ifweasked10otherequivalentlytrainedandexperiencedLinementodothatjob,wouldtheyalsoremovetheshield?(substitutiontest)
19TheRootCause
Wheninstructorsteachthisprocedure,dotheypointouthowthisshieldworksasasafetydevice?
ApparentCauseRootCauseCauseCorrectiveActionResultApparentCauseRootCauseCauseLinemanviolatedprocedureCorrectiveActionPunishlineman
forviolationResultApparentCauseRootCauseCauseLinemanviolatedprocedureCorrectiveActionPunishlineman
forviolationResultLinemandecidesthathiscompanyprizes“accountability”oversolutions,andtellsstoryofthisunfairnessuntilheretires.Incidentoccursagain.ApparentCauseRootCauseCauseLinemanviolatedprocedureTrainingdidnotincludecriticalinfo.CorrectiveActionPunishlineman
forviolationResultLinemandecidesthathiscompanyprizes“accountability”oversolutions,andtellsstoryofthisunfairnessuntilheretires.Incidentoccursagain.ApparentCauseRootCauseCauseLinemanviolatedprocedureTrainingdidnotincludecriticalinfo.CorrectiveActionPunishlineman
forviolationUpdatethetraining.Sendbulletintolocaloffices.ResultLinemandecidesthathiscompanyprizes“accountability”oversolutions,andtellsstoryofthisunfairnessuntilheretires.Incidentoccursagain.ApparentCauseRootCauseCauseLinemanviolatedprocedureTrainingdidnotincludecriticalinfo.CorrectiveActionPunishlineman
forviolationUpdatethetraining.Sendbulletintolocaloffices.ResultLinemandecidesthathiscompanyprizes“accountability”oversolutions,andtellsstoryofthisunfairnessuntilheretires.Incidentoccursagain.Incidentdoesn’treoccurformanyyearsifever.Linemanandotheremployeesseetheircompanysolveaproblemwithreasoninsteadofpower.TwoBriefTeachingCases
JamesMerlo,NERC&JakeMazulewicz,DominionVAPower__________________________NERCHumanPerformanceConferenceMarch202127TheSecondEvent
28TheCause
29
Turntothepersonnexttoyou.
Spendafewminutesfindingouttheiranswertothisquestion.
Ifthisincidenthappenedatyourcompany,whatCorrectiveActionwouldbetaken,andwhatwouldtheresultsbe?Question30TheCause
31The
Cause
Apparent
324-8Questions
Turntothepersonnexttoyou.
Workingtogether,writedown4-8questionsyourealisticallycouldandwouldaskinaRootCauseAnalysisofthisevent.33TheRootCause
Whatledhimtoleavethejumperinplace?34TheRootCause
Whatledhimtoleavethejumperinplace?Didheuseanydefensestoremindhimselftoremovetheleads?35TheRootCause
Whatledhimtoleavethejumperinplace?Didheuseanydefensestoremindhimselftoremovetheleads?Didhedoanythingdifferentthistimevs.previoustimeswhenhe’sdonethisjob?36TheRootCause
Whatledhimtoleavethejumperinplace?Didheuseanydefensestoremindhimselftoremovetheleads?Didhedoanythingdifferentthistimevs.previoustimeswhenhe’sdonethisjob?Washetrainedorcertifiedtodothisprocedure?37TheRootCause
Whatledhimtoleavethejumperinplace?Didheuseanydefensestoremindhimselftoremovetheleads?Didhedoanythingdifferentthistimevs.previoustimeswhenhe’sdonethisjob?Washetrainedorcertifiedtodothisprocedure?Werethecorrectleadsidentifiedontheprint?38TheRootCause
Whatledhimtoleavethejumperinplace?Didheuseanydefensestoremindhimselftoremovetheleads?Didhedoanythingdifferentthistimevs.previoustimeswhenhe’sdonethisjob?Washetrainedorcertifiedtodothisprocedure?Werethecorrectleadsidentifiedontheprint?Ifweasked10otherequivalentlytrainedandexperiencedfieldtechnicianstodothatjob,wouldtheyalsoforgettoremovetheleads?(substitutiontest)ApparentCauseRootCauseCauseFieldTechnicianleftjumperinplaceCorrectiveActionPunishFieldTechnicianforviolationResultApparentCauseRootCauseCauseFieldTechnicianleftjumperinplaceCorrectiveActionPunishFieldTechnicianforviolationResultIncidentoccursagain.FieldTechniciancan’tunderstandhowhemadethiserror,(andretellsstoryforyears).ApparentCauseRootCauseCauseFieldTechnicianleftjumperinplaceWiringandlogicdiagramsweredifferent.Noorganizationalprocesstoverifywiringdiagramsandprints.CorrectiveActionPunishFieldTechnicianforviolationResultIncidentoccursagain.FieldTechniciancan’tunderstandhowhemadethiserror,(andretellsstoryforyears).ApparentCauseRootCauseCauseFieldTechnicianleftjumperinplaceWiringandlogicdiagramsweredifferent.Noorganizationalprocesstoverifywiringdiagramsandprints.CorrectiveActionPunishFieldTechnicianforviolati
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